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PE ARTM S) OF p STATE OF NEBRASKA <br />EDUCATION OF PI HEALTH, DEPARTMENT OF HEALTH � � <br />'., EDUCATION AND WELFARE <br />Bareata of % "ft81 Stntivtl- <br />BIRTH No 126.___. CERTIFICATE OF DEATH S? nT}; FILE NO <br />u PLACE OF DEATH - USUAL RESIDENCE IWh-, aeern.rd lied. If in t ion: residence <br />o. COUNTY .tali -ATE b co�NTY before edmiselon ). <br />I. CITY (I[ t :ids Corp lrote Ilmn. —Re Rurnl) r. L F; N C. T H (>F' c. CITY iir 'de corpo 1 it::, .vrite RURAL) <br />TAY OR <br />I l TOWN .. 'mil O TOWN ;;'irO <br />d. FULI. NAME OF II( not In hone ital or �n.titu ve xtr yI'KEt.I 'If vrsl, No location) <br />{ d HOSPITAL OR ,dd, �.) ADDRESS <br />Z INSTITUTION _rt :_O. -1C 1Ti .. i_0 _.(; u'Y'• <br />3. NAME OF e. IF rat) -- - ti_ (Middle.) - - - - <br />i IIF.CEASED <br />c. Il,ext] 4 DATF. (Month) (Day) (Y or) <br />g' <br />OF <br />Type or Print) -'k_, wJ Vu ..= +I'Cy1T_e A;I DEATH 4 13 1y,b7 <br />5. SEX 6. COLOR or RACE ]. WIDOW MARRIED, Nf;V F,H MAItRIF1 AGE (ln yrn If Under 1 Y ff Under 24 H- <br />WIDOWED, OF BIRTH; <br />j WI1 OWFD, DIVORCED 151 'f ) 1 birthday) Mos. Dny, Novrs Min. <br />lea 1n! - <br />�`• 1 On USUAL OCCUPATION 6 kind of —1k 11b KIND OF BUSINESS 11. BIRTH (C', t nty) (Snoto '12. CITIZEN OF WHAT <br />j <br />,Rno d-in[ 000ut of —kin, 1 f it iced) OR INDUSTRY PLACE o f un y) COUNTRY? <br />J,1 UO .,1111y 1.111 (J1 :, Le`.. ..,. <br />3 <br />FATHER'S NAMF. Ida MOTHERS MAIDEN NAME 14b NAME OF HUSBAND OR WIFE <br />�— _ „�'� ��.:_. .oi �r• ,1111 .,a 3s��e_ <br />'' Ifi. WAS DECEASED EV FR eIN U S. ARMED FORCES? 16 SOCIAL SECURITY 11. INFORMANT'S NAME or Si--c & Addrem <br />A (Y no II (If c've w r or dote. of er rvice) NO <br />-._. --,-A,.__ ZOS.e <br />1 � Il CAUSE OF DEATH MEDICAL CERTIFICATION rY li al Between <br />1 <br />]Nine form ) In) d (<) I I15LA9E ( R CONDITION / d th <br />DIRECTLY LEADING TO DEATH• <br />j •This don not mean the ANTECEDENT CAUSES <br />W1 of dyln[, evch u DUE TO (b) .__... ...... .... ....... ... ...... ... <br />h t f.il.e hthenla Morbid conditl 11 am [.In[ <br />It means the die- he a 00 eon[ <br />Inlvr >, or camplln th d rl>I [ IuL B. TO ( ) <br />\ lion which eaveed death' _. _ _ __ ....... ... .. .. ...... ...... <br />11. 01HER . d <br />° a `°'hy Ge°1 `��ra:ai o ta..ir naielna..a a°in. <br />_ATE _ OF <br />_.. <br />OPERA-'19b. MAJOR FINDINGS OF OPERATION 2n. AUTOPSY? <br />TION _ I Yee N11;-1 <br />1 - <br />21 s. ACCIDENT (Spc f ) - PLACE OF INJURY ( i bo t ''21 e. (CITY 1 TOWN) (COUNTY) (STATE) <br />SUICIDE HOMICIDE ,home (rm, factory, trcet, office bid c[c.)i (If rural a ea, write RURAL) <br />21d. TIME (Month) (Day) (Yee) (Hour) 21 INJURY OCCURRED 'If HOW DID INJURY OCCUR ' <br />OF i Work <br />ot <br />' INJURY N Whit, le at Work <br />22_cehaseel)y c e ton,_ th t �a_ R aJ, anddeceW ed death o `u>red a L-7- 1- -- - that - - saw the <br />y jy � J 93 � to y... / � 19:;/ 7 that I last saw the de- <br />m the ` and on the date stated above. <br />29 SIGNATURE y/�� 236 ADIjS l 7 29 ;DA SICN_ED <br />21a. BURIAL DATE .'de, NAME OF CEMETERY OR CREMATORY ''i 24d. LOCATION (City town. nty) (State) <br />zl CREMATIO [f L i <br />REMOVAL IIISye f ) /.L J/ i. lE: 1 L <br />e DATE RECD BY LOCH I RF14*prAF °rGeti AT{yttE 9 ,. FUNERAL UIIiECTOR S ST ATURE ADDRESS <br />.R <br />